Surgical outcomes of styloidectomy, internal jugular vein fasciotomy, and C1 transverse process resection for venopathic intracranial hypertension

OBJECTIVE: The role of extracranial venous compression of the internal jugular vein (IJV) in patients who have symptoms consistent with intracranial hypertension is a recently described phenomenon. If medical treatment fails to control symptoms, several surgical techniques have been described to address the IJV compression that typically occurs, as the IJV passes anterior to the C1 transverse process. Techniques include styloidectomy, IJV fasciotomy, IJV repositioning, C1 transverse process resection, and IJV stenting, in isolation or in various combinations. The aim of this study was to evaluate outcomes (symptom severity, quality of life [QOL], and radiological change in IJV stenosis) in patients who underwent a single institution's standard surgical protocol of styloidectomy, IJV fasciotomy, and CI transverse process resection. METHODS: Adult patients who had symptoms consistent with intracranial hypertension and radiological evidence of IJV compression were evaluated from January 2023 to January 2025 in a multidisciplinary team meeting. Those patients who remained significantly impaired despite medical therapy and who elected to undergo surgery were included. Demographic data, symptom severity and QOL data, and radiological data were collected preoperatively and postoperatively (3-6 months). Descriptive and comparative statistical analyses were performed. RESULTS: Twenty-seven patients (22 female, median age 40 years) were included in this analysis. Improvements were observed in all 3 domains during the postoperative follow-up period. The mean IJV stenosis grade improved by 1.89 points (p < 0.0001). All symptom severity scores, except for dizziness, showed a statistically significant improvement, with headache demonstrating the most improvement (Δ = 1.85, p = 0.0002). A statistically significant improvement (Δ = 1.13, p = 0.006) was seen in overall QOL, as well as 10 other measures markers. CONCLUSIONS: This case series demonstrated that combined styloidectomy, IJV fasciotomy, and C1 transverse process resection yielded meaningful improvements in symptom burden, QOL, and venous outflow on imaging in a carefully selected cohort of patients who were refractory to medical therapy.